To Round or Not to Round: That is the dilemma!

Juli F Daniels, Ph.D., CCRN, CNE, NEA-BC, LHRM

Background

Patient satisfaction and patient safety outcomes are viewed by hospital leadership as crucial determinants of success for meeting this mission

Centers for Medicare and Medicaid Services (CMS) withhold money from hospitals, with the option to earn some of it back based on the five domains (efficiency – 25 %, HCAHPS – 25 %, clinical care process – 5%, clinical care outcomes – 25%, and safety – 20 %).

Background

There are 12 core measures which account for 70% of the weight while the other 30% are eight composited measures from HCAHPS

The eight HCAHPS measures include nursing communication, doctor communication, responsiveness of staff, pain management, communication of medications, discharge information, cleanliness and quietness of hospital environment and overall rating

Background

25% of falls result from falling out of bed and approximately 30% of these falls result in injury with 4-6% listed as serious. Injuries included either fracture or death

hospital costs for patients injured during falls are US$4200 higher than for patients who do not fall

Background

Multiple studies have been conducted in the past six years to assess the effectiveness of nursing rounds on outcomes such as call light use, patient satisfaction and patient safety

Patient rounding has shown to have positive impacts on decreasing call light usage, decreased fall rates, decreased skin breakdown rates, and increased patient satisfaction, with nursing care resulting in improved patient satisfaction scores

BackgroundPurposeful and timely rounding is a best

practice intervention used to meet basic patient care needs routinely, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur

Studer found hospitals that proactively instituted rounding increased patient satisfaction by 8.9%

The IHI endorsed hourly rounding in 2009 as the best way to reduce call lights and increase both the quality of care and the satisfaction of patients.

The Joanna Briggs Institute (JBI) Clinician Information Recommendations

(JBI) Evidence Summary/Nursing Rounds: Clinician Information describes the following best practice recommendations for purposeful and timely hourly rounding: 1. The hourly or two-hourly nursing rounds are

recommended in hospital to reduce call lights, falls, and increased patient satisfaction.

2. The “12 step” or “4P” protocols can be used while performing nursing rounds

Aim and Objectives Determine current compliance with evidence-

based criteria regarding timeliness and purposefulness of nursing rounds.

Improve knowledge regarding best practice interventions amongst staff nurses regarding nursing rounds.

Improve compliance with evidence-based criteria regarding timeliness and purposefulness of nursing rounds

MethodsThe project was conducted on a 28-bed medical

surgical unit at a tertiary care non-academic faith-based facility in the United States

Direct observation was employed to assess nurses’ timeliness and use of a protocol when rounding

Interventions were developed based on baseline data results and post intervention data was collected on the same criteria

Statistical analysis was completed to determine the significance of study results

Methods The Joanna Briggs Institute Practical Application of Clinical

Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) audit and feedback tool framework was used. The 3 phases included:

1. Establishing a team for the project and undertaking a baseline audit based on criteria informed by the evidence.

2. Reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework.

3. Conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identifying future practice issues to be addressed in subsequent audits.

Phase 1: Stakeholder Engagement Quality and Safety Indicators and Baseline Audit

Three HCAHP categories directly related to outcome measurements for nursing rounds were: a) nurse communication (achieve 82% score);b) responsiveness of hospital staff (achieve

73% score); and c) pain management (achieve 74% score)

Audit criterion SampleMethod used to measure percent compliance with best practice

1. Hourly nursing rounds are conducted at a stipulated time during awake hours

32 rounding sessions on day shift by nursing staff on a medical surgical unit

Direct observation of the time the round started

1. Hourly or 2 hourly nursing rounds are conducted during sleeping hours

12 rounding sessions on night shift by nursing staff on a medical surgical unit

Direct observation of the time the round started

1. A protocol is used by nurses when conducting rounds

44 rounding sessions on day shift and night shift by nursing staff on a medical surgical unit

Direct observation of:

• Verbal use of the “4P script”

• Completion of each “P” of the 4P rounding method (pain, position, potty [urination], possessions)

Phase 2: Design and Implementation of Strategies to Improve Practice (GRiP)

One month later, a staff meeting was held with the nursing leadership and medical surgical unit nurses to discuss the results of the baseline data collected on the three criteria

Identified barriers, strengths, resources and outcomes for nursing rounds

Barriers to rounding which primarily focused on staffing, new unit management, and lack of knowledge of best practice interventions

Phase 3: Follow-up Audit Post Implementation of Change Strategy

The third month of the project, a follow-up audit was conducted

The same evidence-based audit criteria as those used in the baseline audit.

A total of 32 observations were completed on the day shift and 12 on the night shift for timeliness of nursing rounds.

The 4P protocol script that nurses developed, as one of the interventions, was assessed on both day shift and night shift observations

Results

Audit criteria and sample:1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32)2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12)3. A protocol is used by nurses when conducting rounds. (N=44)

HCAHP Goals

0

10

20

30

40

50

60

70

80

90

Nurse communication Responsiveness of hospital staff Pain management

Baseline Data

75th Percentile HCAHP Goals

NDNQI Baseline Data

Table 2: NDNQI data – Medical Surgical Unit Patient Falls - Volume per Month

Pre-intervention Pre-intervention Pre-intervention

1 3 2

Staffing

Nursing unit manager and director will review a three-month staffing pattern and identified gaps to determine additional FTEs needed

Vice President for Nursing will approve budget for hiring needed FTEs

Unit manager and director then will work with human resources department to advertise, interview, and hire experienced nurses

Staffing schedulesPatient assignment logs for last three monthsFour nurses were hired and completed orientation

prior to the March 3, 2015 follow-up audit cycle.

New Unit ManagementUnit manager will actively engage with the unit

charge nurse to evaluate the daily unit acuityUnit manager will assist in performing nursing

rounds when neededCharge nurse availability at the beginning of each

shiftManager following audit criteria for rounding on the

unitNew unit manager presence on the unit has yielded

positive comments from nursing staff to build teamwork and stabilize unit daily functions

Lack of Knowledge of Best Practice Interventions A journal club will be formed and articles on the topic will be

circulated to nursing staff A journal club/QI board was developed to collect best practice

interventions on the topic of nursing rounds A script was developed and put on a reminder card by each

computer for staff to use as a communication tool on patient admission assessment, during rounds while the patient was in the hospital, and upon discharge

The script and the 4Ps added to the nursing rounds documentation section in the electronic health record

Nursing educator to obtain materials for the board Journal club team to post articles on nursing rounds Nurse educator to update compliance with the three audit

criteria Timeliness of day shift rounding compliance increased 25%; night

shift rounding increased 33%, and using a protocol when rounding increased 64%

Phase 3: Follow-up Audits

Audit criteria and Post-Audit Sample:1. Hourly nursing rounds are conducted at a stipulated time during

awake hours. (N=32)2. Hourly or 2 hourly nursing rounds are conducted during

sleeping hours. (N=12)3. A protocol is used by nurses when conducting rounds. (N=44)

HCAHP Comparison

0

10

20

30

40

50

60

70

80

90

Nurse Communication Responsiveness of Hospital Staff Pain Management

Pre-Intervention Data

Post-Intervention Data

75th Percentile HCAHPS Goals

Table 4: HCAHPS sub-categories improvement rates

HCAHPS sub-categoryPre-intervention

compliancePost-intervention

complianceChange Rate of

improvement

Nurse communication

Listen carefully 58 % 71 % ↑ 13% 18 %

Explain things 63 % 71 % ↑ 8 % 11 %

Responsiveness – staff

Call light 45 % 45 % 0 0

Bedpan or bathroom 24 % 65 % ↑ 41 63 %

Pain management

Pain control 56 % 68 % ↑ 12 18 %

Pain help 68 % 77 % ↑ 9 12 %

DiscussionTimely and purposeful rounding was the intervention

determined to have the greatest impact on improving patients’ perspectives of, and satisfaction with, their care, as well as increasing patient safety during hospitalization.

Initial improvement was made toward the established satisfaction benchmarks for the project. Responsiveness of staff, the HCAHPS category with the lowest scores, had a robust 28% improvement rate (a gain of 15%)

The call light usage rate by patients was not evaluated. Call light did not change.

Discussion

Pain management, with pre- and post-implementation scores most similar to those for nurse communication, realized a 15% improvement rate (a gain of 11%)

The project aim of improved safety, indicated by a decreased volume of falls

Discussion

Nurse communication, the category with the highest starting and ending scores, had a modest 7% improvement rate (a gain of 5%). the improvement rates for sub-categories listen

carefully and explain things had higher improvement rate gains, 18% and 11%, respectively. These sub-category results indicate a higher quality of purposefulness and intentionality when rounding and are most likely due to adoption of the standardized scripting protocol

Successes

The use of best practice evidence to promote practice change and management staff teambuilding.

This project has empowered and re-energized nurses to initiate a journal club focusing on nurse driven practices to improve patient care outcomes.

Future directions for promoting best practice in this unit are to identify and address other medical-surgical practice issues related to oncology and bariatric patients by applying the learned concepts of process improvement.

Limitations1. Barriers identified for this unit that may not be

generalizable to other units in the hospital because nursing workflows and patient populations with their specific needs differ in each unit.

2. Results of the intervention unit were not compared to a control unit.

3. Direct observation could have biased nursing behaviors.4. The call light usage rate by patients was not evaluated.5. Sustainability measures needed to be established to

maintain the gains and to continue to improve the outcomes

Conclusion

Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness.

Having an appropriate infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success.

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